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<div style="width:650px">
	<span class="printheader">Payment Slip</span>
	<hr class="printout">
		<table width=100%>
			<tr>
				<td colspan="2">
					<span class="infoheader">File Number:</span>
					<span class="info">CRGIA-2012-013602</span>
				</td>
				<td colspan="2">
					<span class="infoheader">Application Identification Number:</span>
					<span class="info">77ae4922-8b9f-47f5-b451-39d205f36e8e</span>
				</td>
			</tr>
			<tr>
				<td colspan="2">
					<span class="infoheader">Applicant's Full Name:</span>
					<span class="info">KENECHUKWU PETER ANIEKWE</span>
				</td>
				<td>
					<span class="infoheader">Telephone:</span>
					<span class="info">07069554647</span>
				</td>
				<td>
					<span class="infoheader">Property Type:</span>
					<span class="info">Private</span>
				</td>
			</tr>
			<tr>
				<td width="25%">
					<span class="infoheader">Land Area:</span>
					<span class="info">800.0 Square Meters</span>
				</td>
				<td width="25%">
					<span class="infoheader">Land Location:</span>
					<span class="info">BIG QUA I</span>
				</td>
				<td width="25%">
					<span class="infoheader">City/Town/Village:</span>
					<span class="info">Private</span>
				</td>
				<td width="25%">
					<span class="infoheader">Land Use:</span>
					<span class="info">RESIDENTIAL</span>
				</td>
			</tr>
			<tr>
				<td>
					<span class="infoheader">Specific Purpose:</span>
					<span class="info">Private Residential</span>
				</td>
			</tr>
			<tr>
				<td colspan="4">
					<span class="infoheader">Paid in by (Full Name/Leave blank if same as Applicant''s Name):</span>
					<span class="info">.....................................................................................................................................................................................................................</span>
				</td>
			</tr>
			<tr>
				<td colspan="3">
					<span class="infoheader">Amount Paid in Full:</span>
					<span class="info">............................................................................................................................................................</span>
				</td>
				<td>
					<span class="infoheader">Amount:</span>
					<span class="info">&#8358 ...............................................</span>
				</td>
			</tr>
			<tr>
				<td colspan="4">
					<span class="infoheader">OFFICIAL PURPOSE ONLY:</span>
					<span class="info">.....................................................................................................................................................................................................................</span>
				</td>
			</tr>
		</table>
</div>